Provider First Line Business Practice Location Address: 
525 HATHAWAY STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FAIRPLAY
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
80440-1600
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
719-836-2169
    Provider Business Practice Location Address Fax Number: 
719-836-2375
    Provider Enumeration Date: 
12/07/2015